languages, religions, and racists who are all seeking health care. many of them are immigrants, some are legal, some are illegal. many of them are spanish-speaking and in a wonderful gesture trying to become a better position danielle ofri took a year's leave of absence from bellevue and she and her family moved to costa rica where she could immersed herself into spanish. ..

is really wonderful to be here. i am an intern this, and the work of bellevue hospital contrary to popular belief bellvue is not a mental hospital. it is a general hospital. it started in 1736 and continues to this day and as a public hospital in new york it has been a magnet for the immigrant population in new york because the stores of an open to all regardless of background and

bellvue has seen the waves of immigrants over the centuries. irs, jewish, aripeka emigrants all colors and flavors and in bellvue all the signs are in three languages but apparently 40% of the illiterate speak none of those languages. emigrants continue to come to velveeta even when they have moved onto planes in westchester because bill do you is hospital to have immigrants. the origin of this book started that year in costa rica. i had always had the fantasy of writing in novel and i can't, couldn't imagine writing fiction in the way that i write non-fiction which is piecemeal essays. i have this fantasy of leaving another country, would learn spanish, my children would be immersed in the language in another culture so we worked a year in costa rica. it was a wonderful year. that is right to cut the cello

and started working on this novel len had a wonderful free anderton 50 pages but it turned out my editor and i read those pages and they were okay but they were not great so we decided to tuck it under the bed with the other novels that were gathering prime real estate does but one of the things that would seem to catch your eye and seem to and treat me was the theme of the emigrants and they seemed to fascinate me and i have all these characters who were immigrants from all these different countries so we decided to go back to non-fiction and focus on emigrants and the different populations that come to bellvue and i think it is not an accident. there is to me metaphor between immigration and becoming ill where people immigrate from a land of the healthy to the land of the sick. desai, rating to a new country. there is a new language, a new customs, amores and often you feel dazed and confused even if these think the language-mankin wish indie need a translator and sometimes your physician can be that person and sometimes they

are not. many people lack the experience of being ill often find they feel like a foreigner in this strange and bizarre culture of medicine. those parallels and treat me and then when i was in costa rica, how have the somewhat unexpected experience of being a patient in costa rica. i which is having a baby but there was a chance to see what it was like to be in a vulnerable position when you don't have a command of the language and things are going on around you and in language that you have to concentrate on and gave me an appreciation for what my patients must go through. on a given day and build the there is every language. is speaking which only occasionally are with an interpreter and i wanted to start with the short reading that is an experience that took place on the immigration war. i spend 80% of my time in the clinic and 20% of the time on the inpatient. one month later i was back on the impatient.

the united nations does have some flamboyant celebration for quadagno think you jim wisdom bellvue was not an official part of it but because only a few blocks down the road for the u.n. we were the recipients of the fall of. the scene in the hospital was not too dissimilar from what i imagined the general assembly of the united nations to look like. on voice from different nations were collected throughout the arf. identifiable by distinctive dress and accent. there was the diplomat with acute gastroenteritis. there was the pakistani attaché with an acute myocardial infarction. his cohort was hobbled by the monitors in this aye. aks was non-governmental worker had chipped off the curb. his group wharfs league double-breasted suits. the estonians were louder anxious that there undersecretary's mike green receive minute to minute monitored. um illation driver with an

asthma attack settle for in the corner. 15 of his compatriots hunched over his nebulizer fingering the trimming and inspecting the monitor. when our team was up we were signed a 26-year-old tibetan hunger striker who had been brought in against as well. he recently immigrated to the united states. he didn't speak e- of english. quickly gannett sword by the tibetan community. the tibetans for of full force during the celebration protesting china's refusal to recognize tibet and the iron fisted approach to the democracy movement. he had been on hunger strike for almost a week along with a group of monks and fellow political activist. during the shopping massell who is some chinese during the human rights rally mr. tenzin felt woozy and search for a place to sit. groping for a bench outside the mascotte sea became separated from his group potentially staggering to the corner.

there they policeman tried to assist him. he bolted but the only managed a few yards before it collapsed in an ambulance was called. now he lay on a gurney in the hospital emergency room a real thin man with a shot of course black hair. he looked fit it, frightened. mr. tan's and ripped out the ideal place by the emt and a bloody bandage was all that remained on his arm. his two hands gripped the state derails of the gurney and his knuckles pill from the compressive force. he looked as though he involved himself over the real iffy have the strength. there was no one in the rtr that spoke tibet and. someone called at&t but didn't have an interpreter available. call back in an hour we were told. mr. tanden's blood pressure was low and his pulse was racing. indicating severe fluid

depletion. his life was not in immediate danger but he needed urgent titration. when we approached him we could smell the rudy tandja ketoses on his breath. as the interim began to sterilize his arm he pushed his way. i tried hand signals to indicate in id in the fein influenced lowing in but he yelled something at me. it was obvious he didn't want our medical care. because of the serious nature of his condition it was imperative for us to assess his decisional capacity to refuse treatment. more important we want to convince him to accept treatment. i called back at&t, still no interpreter available. without an interpreter he was isolated in in in penetrable bubble. and orderly with the crew cut in football sized biceps strode over and listened to a gurney without a word.

when nagourney moved people themselves up, his eyes widening in panicking began protesting in tibetan, where are you going? 17 ortiz knapik evette tutu-- tett to. abed is ready and when the bed is ready we have to give him up right away. he his head with his international else. he pushed his gurney into the service elevator and their teams scramble to catch up with him. the service elevator at feldy was a no-nonsense of their industrial steel walls filled from years of facts pressing up against them a scuffed linoleum floor harsh fluorescent lights and a cranky elevator operator glued to a worn wooden stool. where to the operator qanta desiree piled into the car. 17 the orderly said. stepped on it. the doors rumpled clothes than

the elevator lurched upward with a joke. he was silent now but his fear stricken eyes went from one corner of the elevator to the other. his fingers were still gripping the bars on the bernie. the muscles of his arms quivering from the effort. the elevator operator sat hunched on the stool had sunk into his soldiers, the collar of his jacket reaching to the top of his ears. he stared and moving at the buttons directly them from of him. they are keeping busy tonight. i was not sure to come he was talking but the orderly answered. the er is busting at the seams. now i could see the right by satz. it said denise. the elevator operator continue to address the council in monotone. i hear that stuff is happening at the u.n., everyone knocking everybody over. yes, like this chinese do here looking down at the patient on

the currency. he is not chinese i said, he is tibetan. itis get them where they have to go. the operator punch the buttons on his counsel in never shifted his gaze towards any of us. tibet food is different from chinese food he said. less ricci, more soupy. and pediatrics juan brought me some tibetan food. the elevator tron latoya hault and we all spelled out. the orderly hustled him to his room and i grabbed one of the medical students. go down to pediatrics. cfu kindig up the knerr sade from tibet. 20 minutes later the students returned jubilant that having located the sole representative of the tibetan h-net bellvue. then there's aid was well under 5 feet with a brown face and silky hair pulled into a tight

bun. she was monumentally pregnant. the protuberant belly on her stature suggested dangerously unstable structural dynamics. nevertheless she moved. her last name was doah of. i walked beside her on the way to his room. she nodded but said nothing as i reminded her that we need to assess the decisional capacity, explicate the-- when we enter the room this didden quickly pulled a chair up and it didn't look like she could stay standing for much longer. when she dropped into the chair for headlines right that the level of his attorney. she began speaking in a low we have voice and the effect on him was immediate. his hands loosened the grip on the rails, easing themselves them onto the bed. the agitated corrugations on its face settled and the tier in his eyes reseeded.

this whole body seemed to say. ms. doah did most of the talking. he offered only occasional one word answers. for 15 minutes she spoke while the rest of us watched in silence. her voice resembled an oboe and the lower registers, airfield lagat no. it has a mesmerizing effect on all of us including mr. tinzan. abruptly she stopped speaking, stood up and turn to west. you may proceed she said, there is no problem. the knerr sade divoted toward the door and we jump to catch up with her. what did he say? he did not say anything. i told them what they remember of tibet when i was a girl. reminded him about the beauty of the country in the mountains. i told him the mountains would weep if we lost him. she press the button for the service elevator. i told him it was okay for the fact to be over that was okay to

eat. that is all he needed to hear. the doors opened, the ukrainian operator was still hunched on the stool staring at the council. she entered and leaned against the far wall reaching one hand under her belly. he will be okay she said and the doors close. when we return to the brown mr. tinzan stretched his arms to us resting his farm on the middle rail. van turn pulled out a tourniquet and began prepping for an id. mr. tinzan did not flinch. his eyes closed as the fluid entered his veins. when i stopped by an hour later one of the nurses' aides was helping him with a bowl of broth. fade chatted to her church encouraging him to sip once gloomful. with each bite she cajoled, mr. tinzan hesitative and accepted until it went round

after round until the bull wasn't. the d.a. did not let up her monolog for one moment. as i turned to leave the eight tore open the top of the chocolate pudding with gusto. she radovan evidently with praises about bellvue's putting. mr. tinzan opened his mouth for a buy-in it was clear he understood. it was well past dark when i walked home from the hospital. the street lamps created parallel orbs of light illuminating the north-south artery. looking uptown i tried to convince myself i could look at the united nations perched on the rise in the typography 14 blocks from where i stood. the truth was it was all the temple of lights but that didn't really matter. i knew it was there that microcosm of the world crammed into a monolithic office building. i often thought of the u.n. and bellvue is sister organizations, both trying to cajole it babil of cultures and languages into a

comedy of political or corporals are. in any case i was relieved mr. tinzan was getting the medical care he needed that this body would finally be able to rest and perhaps kissell could too. by the time i got home supper was finished in the kids were ready for bed. i talked open the door. i elites to the menus for the local afghan the chinese tie and turkish restaurants. i put aside the mexican japanese italian and morroccan once. i knew there was a tibetan restaurants in the neighborhood sandwiched between the locksmith and library but i have not been there. i sorted to the indian pakistani vietnamese menus until i found it. there were dumplings made of barley flour and butter, stews and curries'. i settled on the savory soup with himalayan and bean thread noodles. i ordered to portion since i

doubt if mr. tinzan's system was ready for the eggs and dry toast that would show up on his breakfast tray tomorrow. thank you. [applause] thank you cannot would be happy to take any questions. >> as someone who spent some time in tibet everly enjoyed your piece. i would like to ask you a little bit about the experience that you see of foreign born physicians to come to the united states to practice, what you think their perspective is in conversely a number of american young people and maybe not so young go to the caribbean to go to medical schools there and the dynamics must be interesting as well so i would be curious as to your views of becoming a physician or in getting more

training as a physician in different cultural settings? >> that is a wonderful question. as i was writing this book there was one section of where i was writing about religion. when patients seem to be talking about religion and i was looking at the house that in the demographics have changed since i train tisha to quite a bit to southeast asian. and formerly, it was entirely white, a chinese or jewish. and now that is completely changed. and what is interesting is i think that creates a comfort level with their use to doctors unpronounceable names and they speak a language they have never heard the. there's so used to people being from various places and it does bring an interesting perspective. i recommend the book my own country when he talks about practicing in appalacia and hell

stereotypes play a role in conflict with various images of the sea so i think it is then credit benefit to diversifying our workforce. i think the patient base is diversifying faster than the physician vaso there are 23 immigrant groups a step ahead of the doctor said there are groups that we have never encountered before and languages we have not heard and dialects we cannot get interpreters for. and i think americans training of bracket this experience of seeing other cultures. there is another world out there and things are done differently. even spending time in costa rica, medicine was different. things were clearly different and i would not have known that if i hadn't been there and had a chance to be patient. >> thank you so much for the buck and the topics. edisto m4 compressco imf physician assistant and part of the emergency medical reserve corps in sciquest and actually is around the issue of

translation for people who do not speak english. i ask this question, let me first explain during an exercise, having been born in denmark i was, i spoke only the nish in an exercise to work with the whole issue of emergency in the community, and it took eight attempts they are using telephone, through using people to try and figure out that they couldn't figure out which language i would speak. i was speaking only danish, and i'd ask the question, to help us understand, what kinds of attempts are being made at your hospital or that you know of to help with this issue as we do get more and more people who speak many different languages and it is for all of us and

community to be sensitive to these issues because it there should be an emergency in our community the really need as a community to help in whatever ways that might be and if we know languages we can identify. but you may know of some things that are being done that could be helpful for us to think about. >> thank you for that question. and that there has been quite an evolution so when i train there were none except the kurds who spoke spanish and orderlies who spoke chinese. often it was the 6-year-old child, the barely-- uncle calling from his taxi. whoever was available in there were clearly pluses and minuses to this system. the at&t operator became the last resort. it was very expensive so we were admonish to use it sparingly and also had to hand the phone back and forth.

then we have volunteer interpreters, often students from beilin will holmes would come from local colleges to spend the afternoon that there was only french on wednesday afternoon, then dolly on thursday morning but he tried to set up a patience that you could. and then we got the two phone, the two self on headsets for you had to cell phones, to head sets you wired up, and tangle them and dial and coats and you could get six languages and that was a marvelous thing although you constantly have to one thank the funds for a good thing you have a service that was purchased and they came within phone with to handsets and you could dial in for certain languages but there was only one phone per floor so you had to find a phone, get the key so that could often be a barrier. now we have interpreters in house and i have a bit in the book about that so there's certain number of interpreters and house and we have remote simultaneous translation which

is an incredible thing. i call 1-800-and press hound for french and a french interpreter materializes. we now speak simultaneously sell my patient began speaking and as a beat or two after that i start hearing in which in my ear and it really does feel like the u.n.. it is an interesting phenomenon to have this translation. for starters the patient is speaking at a regular volume talking fringe, west african french usually pick of the interpreters speak very faint english in meir, and i can't focus on the english from hearing this french loud and clear so i have to turn out the patient. of course we are trained to focus on the patients gillet nord cantor preparer and put the interpreter behind the patient but there isn't any way to have their brain focus on what you are hearing and listen to the words in the meaning while someone is speaking in front of you so i find that doctor and

the patient would go away. we both naturally do this because we get to discombobulated and there are two different languages at different tempos going on, so it has that in practicality and i would say probably also loses the part about choosing, the parti gidget the connection or you talk about family, what you do, how did you get here, said things that seem less relevant but would cement the sense of trust and when you have an interpreter you feel bound to get to the practicalities. you can't just chat so i find that it is much harder to have that aspect of the relationship, the part that can often be the most fun but it is eons better than what we have in now with these the patient can make themselves understood. at least their language can be translated. that is a mean their culture can be translated so there can be many challenging things. there's a section in the book where i was talking to an

interpreter and he was confused about the terms illness and disease because and french there was one term as there is only one turman spanish india trouble interpreting that. he also had trouble with abbreviations like h-net, but then he asked me, what is up with the term water pill? why do doctors so we say you are taking it water pill? y no aegis sade dire reddick? first of all the dire riddix we have our hydrochlorothiazide, so it seems to complicated and the word dire reddick seems over technical so we all say the water pell, the pill that make to produce water. he said, to most haitians at what repel has nothing in it. it is just a placebo. i said, really? is that with my patients are taking? no wonder no one takes the medicine cyberspy. in english we call placebo a

sugar pill. he said for haitians, it is a real thing but the water pell sums like nothing. that is why it is not getting across of the various cultural things that transcend actual language. he then explained to me the patience he speak to ed haiti from growing up he knows there is no concept of an illness without a visible wound selleca italie patient's they have cancer inside their body or hypertension and they do not see a wound they don't feel sick and although they will say yes to everything that doctor says for being polite they won't have any concept of having treatment. and he cited many situations in which he could translate the doctor's words and the names of the disease particularly cancer. there was not a concept for a dent haitians would say yes and never show up for follow-up because they didn't feel it was a nellis until they saw and losing wellen gannett that when it was too late. they often need to be cultural interpreters and that is a whole

other brown and their job is to translate the words in the language because sometimes they will have to stop and say this concept is not getting across. looking for a disease before you have it. and then there is now issues of liability. now the translation services are so routine in mandated can there be malpractice based on an error from the interpreter? i am sure the interpreters are terrified and i realized i concede there is still a layer between us even though i have someone whose fidelity is transmitting the words. i can dolly's be sure that someone understands. reminds me once in the days before interpreters having an elderly gentleman who spoke only mentor in and his grandson spoke mandarin so the interview went on up and down the line, up and down each question ended each level there would be debate and discussion and argument and it would come down to six rounds

later i would get a three word answer. everyone had their layers of not just translation but their opinions to go into it so there are many aspects of translation beyond just the language. currently in our hospital there are signs everywhere that have about ten languages and that language, i speak korean, yiddish. i need an interpreter so someone can point to the sign. if you don't speak one of those 20 languages then you-- but it can be difficult that these p.k. were of language. i have a woman on the award this past month to spoke a dialect of chinese that almost no one spoke in there was no operator who spoke that dialect than someone who spoke cantonese could make yourself understood to the patient, but we could not assure the woman understood what was going on so there was always a challenge going on.

>> i was wondering if you saw this recent article in the "new york magazine" that spoke about the americanization of mental diseases and kind of what they explained was that western science and in particular in the mental illness realm was so elevated that mental diseases carried out side of the western world for almost like pushed aside or were read diagnosed in there for the traditional methods of carrying those are treating those diseases were also overlooked or disregarded and i guess there is an inherent danger in that. and i was wondering at bellevue hospital, kind of ever trained there because you have to deal with such a multicultural patient, patient's, you know, trains doctors in non-western

medicine or techniques, because there is these cultural discrepancies? >> we are not get that-- that we have multifaceted education and probably shing clearly mental ellis is an interesting subject because so many aspects of mental msr cults rory determent. when someone is psychotic can be culturally determined and also some things that might appear psychotic and western culture are in fact part of the culture that are not a symptom of mental illness. gude duest back in haiti as the gentleman was telling me can come across as psychotic, as delusional get their completely except it aspects of normal functioning, said there is kind of a whole set of variations that the culture, a wonderful book-- which really shows how the cultures vary so greatly and butter definition of illness is

particularly mental illness or neurological illness in this case can often be quite different so we can often miss the boat so we probably should be getting more education. at this point most of this get the education for more patience. it is the place we need to strive for. thank you. >> can you talk about what you see as your covenant with patients in terms of being the one who tells their story, instead of them telling your story as you write, as a writer? >> what are the ethics of writing about a patient? >> how do you you feel about what your obligations are and how much-- and how much you can say. >> that is obviously a fascinating question of when that concern to anyone who writes about patience. there many issues there. legally, when i first wrote my first book i thought-- risk management and they said there's only two issues legally, there

is lightbulb that you are not committing level in you change the patient's name and you were done from our perspective. but they think that for a doctor, the barn needs to be much higher. clearly this is not a journalist , this is for publication in the patient comes to you for help. they are vulnerable, they are trusting and there's an assumption of confidentiality so the bar has to be very high. when i first started out i made it my business to attend every lecture and ask that question what do you do and the answers vary. their stories, your stories, it is your story too. as part of a therapeutic maneuver the paging kington-- correct when things are wrong so there is a whole variety of opinions. for me one of the things at least my first two books a lot of time pass from when the

offense occurred divine i wrote about them and the truth was that that point many patients for farc on in many respects. i probably couldn't have contacted them, but i did have one patient in my second book. justice the book was going to press the had an interesting patient and i wanted to write about him. when i went to see him he was a gentleman who looks kind of homeless although he found an apartment which between a bathtub and the sink and there were things piled up in the head and come out and it was just a strange story. he just looked really like he had been beaten by life but he told me all the stories about being in a small business hall of fame and all the things he invented and patented in lectures around the world that just didn't seem to jive with whom this fellow was. my book was on his nightstand and then never talk about writing and it turned out the neurology-- and, so i told him i

wanted to write about him. he said sure, just let me see it. my editor was appalled. she said no, i am the editor here. i said they feel as though i need, one of the cardinal tenants is it can be harmful to the patient. if the patient found it uncomfortable i could not publish it. so i sent him the manuscript and i waited and waited and finally he called. i was sure he would be concerned about my implications he had an unraveling of this light that clearly he had a functional lighting clearly reached a state that the their mental illness or paranoia or something and it really wasn't where he was. that is not what bothered him. what bothered him was the physical description of what he looked like some of the part of it called the most objective because he did not see himself that way. he said, is that what i look like? the truth is that is what he looked like. he had never seen himself and i

was holding this mer to him. he was crushed but he said it was ok to publish so i invited him to the reading. he showed up in a suit jacket, dark hair and silver cane and i had never seen him in a healthy state so it was an education for both of us. if i can, showed the words to the patient and in this book and showed that to some of my patients and i showed them the manuscript so i would like to give their consent and their approval. if i can i have to make a decision do i think it is a respectful rendering? i want to honor my patients and this is clearly subjective but that is the bar. i have a great story about a patient who lied to me and the implications of that relationship and it really touched a fascinating topic of that doctor patient relationships. he is a poet who reads literature and you know he would be heard it the sought.

one more question. >> it is kind of related to what you just said. do you encounter hipaa problems? >> then there is set up. hipaa is the bane of our lives. hipaa is the law that is intended at least in part to protect patients' confidentiality and it has become a nightmare bureaucracy and makes it hard to function in general although i appreciate the underlying theme of the law. so, i don't know the answer to that question and that figure when the lawyers call me then i will know. so i want to talk to you a little bit about one aspect of the book, about our survivors program. there is a wonderful program that helps patients who were seeking political asylum and we get referrals from all over, patience from many countries. the diversity of abuse in this world is staggering, and the

program is comprehensive providing psychiatric, medical and legal support. for the medical side they ask for a volunteer to screen them and most of this volunteer one session a week. most people can't do more than one so for me mondays at 1:00 is my time. i never know what that they will bring. last monday i had a gentleman from afghanistan. a lot of west african patients, tibetan, eastern european patience and they bring very unique problems. most of them in fact there quite healthy. political opposition tends to be the-- for the young and healthy. they tend to be young and robust despite the physical, psychological and sexual torture so i don't have much medical to do them. it is where they have a medical illness but most of them have post-traumatic stress disorder,

nightmares, flashbacks and difficulty adjusting to american society. sometimes they find is free and open as america is they can be overwhelmed and days from the experience so mondays at 1:00 our my hardest times of the week. tuesdays are the days i'm not in the hospital. tuesday is my cello lessons and it has become a bit of a chance to unwind from those mondays and i will read you a brief section from that. my cello teacher slipped to photocopies sheets of paper from his back in smith amman to my music stand. the moment had finally arrived. after three years of sweating through scales and simplify the excerpts it was time to start the block. the six unaccompanied cello pieces are preparatory. the first is the most famous and

has been overplayed to the point of sentimental. but like other overplayed works, motzert's music the underlying music is still spectacular. no matter how often it has been dredged up from tv commercials in cell phone ringtones. to listen to it may feel overly familiar but to play it, that was another matter entirely. it was an opportunity as a doctor colic once put it to touch the hem of greatness. monday afternoons where patients were daunting. the breath the brutality of human beings never cease to astound. the energy and effort and creativity invested in destroying the human body seemed limitless. what sort of response could i offer that was meaningful in the face of overwhelming trauma? the matter what i said there did with my patients i always felt useless. it was a different feeling of uselessness then i felt for

example with the patient dying of cancer. dizziest no matter how painful or humiliating or self-inflicted was something that occurred. disease utilize intransitive verbs. but torture was transcendent. done by somebody to somebody. having a leg amputated because of complications from diabetes was not the same as having it hacked off by a machete. i felt as though i had something in my repertoire but i was at a complete loss for the sierra leone in his arms had been machete go. it was not just their treatments to prevent the next amputation but the diabetes was an entity separate and did not have the face. nobody did diabetes to any one. the disease just occurred. torture on the other hand had a face. somebody an actual person did it. a human being raised in nye fin pour the acid he's the blue, set

the fire and that i think is what made these counselors so unsettling above and beyond contemplating the horror the victim had endured. somebody did this, some member of our humanity and whether i like it or not i was part of that same humanity. the sheet music of the first box wheat appeared straightforward. to pages of notes in the key of g. no double sharpes, no key changes, no fancy ornamentation but is anyone who has tussled with bach no's that simplicity is ruthlessly deceptive. one measure of the time my teacher instructed me, it needs to be completely mesmerized. expect to put in a year on this. this was said without irony. week after week month after month i tiptoed gingerly through the music. unfun myself focusing narrowly on a single page, a single line,

a single measure even a single note. temperamentally this was the exact opposite of the meaningless minutia that clattered the halls of the hospital. all efforts need to be focused on struggling to achieve precisely the right note. but then there was a step even beyond that. the note did not merely have to be right, it also had to be beautiful. beauty gets short shrift in medicine. beauty is some pragmatic. it doesn't enhance efficiency increased productivity of bernie grantor curiae patient's but it feels necessary for ago when i survive the measure that beauty was astounding. the type of beauty that really does take your breath away. i sometimes feel as though i have to stackup against mugabe, hussein bin laden and the dictators the third round the globe. there have to be a counterbalance in the world of balance that was metaphorical

and actual. to live in this world, to accept such cruelty was the reality i had to know that beauty was a neat will reality. even have some human seem to exist solely to walk for pain and destruction there were others who insisted the only to create beauty. the chance to feel the beauty grays the cheek was sometimes see only thing that kept the last straw at bay. thank you. [applause] >> tinzan is an attending physician in the medical clinic at bellvue with an academic appoint minute nyu an addition she is the cofounder and editor-in-chief of the bellvue literary review. for more information tinzan.com.

>> we are and george washington university with sarah binder who is the co-author of "politics or principles" filibustering in the united states senate. to begin with, what is a filibuster? where does that word come from? >> the word actually comes from the dutch, from a word i think they call free word when translating which basically applies and meant pirate to our marauding across the seas and were killing everything in sight in sword is the idea that filibustering centers can't be stopped and they can talk and talk until only supermajority of the senate can cut them off.

>> how did it start? is there such a thing in the constitution? >> the constitution says one thing of the congressional rules. it says the house and senate can set their own rules. fun enough the house and senate in 1789 have the basic sing said of rules. posen until early in the 1800's the senate having ruled which the house has today. we call it the previous question motion. it is used to cut off debate by majority vote. the senate had it. they did not know how to use it. they go to feist to clean up the rule buchan habicht does and once it is gone there is no way for a majority to cut off debate. i don't think the senators really understood what they were doing in 1806, but when filibuster start to heat up then partisanship heats up in the 1830's and the great centers we talk about want to debate, they can't because there is no rule in the senate rule book that allows the jordee.

>> couldn't they have just change the rules? >> overtime, senators have tried to change the rules. they have introduced rules. what happens when you introduce a rule to ban the filibuster? somebody filibuster's it so we have filibusters to change the filibuster. there is a process for a changing the filibuster but it takes 67 votes and we just got to 60 votes in the senate with democrats and still we don't have 66 votes to change the rules. >> what are some of the earliest uses of the filibuster? >> we see filibuster start in earnest in the late 1830's, 1840's and they occur on the big and small issues of the day. we see them on the national bank. we see them on andrew jackson's behavioral for the bank. we see them over slavery, we see them over extension of slavery and territories and of course we see them in civil war and

beyond. >> what were some of the earliest successful uses of filibuster? >> well, in each of these episodes we have seen successes. we see minorities blocking the extension of slavery. we sea battles over kansas and nebraska. we sea battles between the democrats and whigs over and jackson in deposits from the banks. it is pretty successful rather early on because the minority if it is intensive enough canal less the majority. >> from what i have read in 1917, there was some sort of a landmark defense with woodrow wilson in world war i. what is that about? the in the run-up to world war i woodrow wilson is trying to get the senate and house to pass a bill that will allow them to our merchant ships. that bill liz filibustered.

eventually wilson goes public. he says look there is a band of what he called willful men, a little band of willful men blocking essentially the u.s. farming itself for well 41 and he essentially shames the senate to pass the bill and then he calls for the creation of the rule 22, the cloture rule. he says this is a war measure and we cannot be a nation that cannot go to war and creates the cloture rule. that allows senators save very hard supermajority to cut off debate. >> as a scholar studying this issue at that point what is your opinion of that? is that a good thing? is that it that thing core does not enter into it for you? >> the idea to get a cloture rule? the senate, but for then was essentially ungovernable. when we look at today's senate we say this is terrible.

it is never been so partisan, never been so petty but if you look at the 19th century zenit tubeless just as bad. they had issues over civil rights obviously, over anti-lynching laws, poll taxes, all sorts of issues coming up that the senate could not act and in light of that, it seems pretty appropriate for the senate to try to change the rules of the games so it least supermajorities can work. it would be better if the majorities could work their will but as of yet we have supermajority rules. >> what about the house? why aren't they the same? >> the senate early on, i think by mistake got rid of their pivotal previous motion, the rule they need. the house kept it in fact the missited in a way that it became an instrument of power for the majority party and majorities realize that so they had a pool that cut off debate and they used it to get other rules that empower the majority party.

let's say we want to rule that you can only talk for five minutes on an amendment. the majority proposes the rule in the minority tries to block it but they can't. the empowers majorities over the history of the house. today we have basically the house majoritarian, strictly one party and in the senate the precise opposite not because it was intended that way but that is the historical accident. that is how they develop. >> what about the notion that the senate is 80 saucer that is supposed to cool heat. is there any kind of contention from the founders from the filibuster was there? >> the true answer to that is no. the founders knew full well the dangers of supermajority rule and they had it under the articles of confederation. the confederation could not act until they replaced it with the u.s. congress. they knew full well that supermajorities meant minorities

could take legislative bodies costed so they thought we have the power to create our own rules but little did they know the direction the senate was going to take. >> a lot of people who think the filibuster probably think of jimmy stewart and "mr. smith goes to washington." that seems like a classic thing. we don't see that on c-span. why don't we see that on c-span? >> this is the question everybody reasonably ask, why doesn't the majority forced the minority to stand up just like jimmy stewart? we call it bring out the cots. why not make them filibuster? the argument today goes, republicans filibuster and the assumption is republicans will be shamed and give up the majority will get what they want. i don't buy it for one instant. first of all the minority party i don't think it is so much of a cause for them if they think they are going to win. their position to republican

constituencies over health care and many issues is popular so there is probably a benefit to them talking all night. but to the majority party-- if you take the floor and filibuster for two weeks, three weeks nothing else gets done. the majority has agendas. they want to use the floor to get things done. even the minority party senators want to use the floor to get things done and if you wrap the senate in filibuster night after night after night what is going to be the end result? the public is going to look at it in say, what are you doing? legislate. i think the cost to the majority are far too high and the minority might think it would benefit from it and they think that is the party keeps senate leaders fromnflame that strategy. >> in our history there have been times when people listed on the floor for extensive powers, right? >> absolutely. we can point back to senator

strom thurmond during the civil rights act in 1957. he was on the floor talking for over 24 hours. there have been some since then, ten of 12 hours by senator d'mato overate type lighter-- typewriter plant. they become famous but they are very few if not nonexistent today. >> isi chart in wikipedia-- wikipedia that has this chart a filibusters going up-and-up and up now more than in the previous decades. is that true? >> what will, technically it is hard to count filibusters because often today senators just radden. what we can count are cloture votes. comedy times is the majority leader gone to the floor and tried to get a cut-off debate and when the count those coming right up and exponential increase after the 1970's, and

increasingly higher certainly in the last couple of years so there's no doubt leaders are trying much more often today to use cloture to cut off debate. now, amid the majority will say the minority is obstructing and we have to in the minority will say you are much too quick to the drop. give us time to talk before use left us with a cloture motion. >> where you come down on that? what is the cause? >> it is a little bit of both. these are senate leaders who have for the last 20 plus years, they have been trying and trying to adapt to an obstructionist tactic and every time the majority does something the minority finds a way to get around it. and cloture is really the most visible effort here by a majority leaders to try to clamp down on predictability to the senate and if we think legislative bodies are basically there to legislate or please consider things carefully and come to a vote, we need in

newt-- even if the bill does, that is what filibuster's prevent. that is what raises my alarm bells about the senate. >> a lot of commentary now suggesting that republicans have 41 in the senate and therefore they run the senate. where does that come from? what you think of when you hear people say that? >> it is a recognition of the reality of what we now called the 60 votes senate, that once minorities understand they have the votes to block culture-- cloture and once there is a partisan incented to disagree, not just the policy incentive but partisan incentive to disagree with the other team minorities are willing to exploit their rights to do that, so it the majority is going to work they need 60 votes for they only have 59, the new wisdom here is that they makes it

exceedingly tough for the majority to work its will. they have to incorporate minority consent. the question today is how our democrat's going to unties enough republicans to come over to vote with democrats and that is a tough call. >> i want to rescue about your suggestions for reform but first i don't know if you have looked at other countries in the world but is there such a thing? does the filibuster exist around the world and if not why not? the i don't know enough as they should about the legislatures and there's some legislatures that have these types of supermajority requirements and they keep them for raising taxes and selectively use them. we know california has one to pass a budget coming anything related to taxes. they find legislators that have a very tough time moving. >> what do you suggest in your book for reform for the senate

rules, or do you suggest reform? >> we publish this book, steve smith mendyk back in 1997 at the height of the efforts again to try to reform the filibuster. there are a number of things that could be done, all within the sort of formal framework of the rules. one, we could get a process to slowly ratchet down the number of votes required to invoke cloture so 60 votes the first time you try, three days later another cloture motion, 57 and then 54 and 51 votes so over a period of two or three weeks to get down to majority rule eventually and that preserves the minority's ability to debate and try to change minds but also preserves the majority civility to act so that is one possibility. the other possibility is to cut down the number of opportunities that are debatable and the senate. right now you can filibuster motion to proceed to a bill. they haven't got the bill on the force of that filibuster keeps

bills off the floor altogether. there doesn't need to be a filibuster on that one. their three motions to go to congress in the house. that is crazy. even one would be enough if not none. they should be able to go to conference and-- you can still filibuster the conference bill. this and that periodically, actually even though we don't recognize that they create what are known as-- procedures. we see it on budget bills, what we called reconciliation. the war powers act has a filibuster ban. antipredatory bill has a filibuster band, m4 ammons, energy all sorts of issues are embedded in the statutes that have filibuster bands of the question is, could the senate selectively create some of those to apply to judicial nominations could they apply to foreign spending? could they apply to health where? episodes like that.

>> what is the so-called nuclear option? >> republicans 2005 were very frustrated with democrats filibustering judicial nomination so they came up with a series of rulings that they were going to try some of which have been tried in the past but they were going to not change the rules formally but to re-enter the rules, which is why it was nuclear. it set democrat's of saying you can't reinterpret the rules to say they mean something they don't mean. so they said we are going to take the cloture rule and in a series of steps by majority vote we are going to interpret it to mean-- democrat said look at the letter of the rule. applies to motions. it applies to nominations. and through this series of steps they are going to do away with the majority vote. that was nuclear because democrats said if you do that we will blow up every bridge in